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Chapter 30: The Appendix

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The incidence of appendectomy for acute appendicitis was decreasing in the United Status until the 1990s, at which point the frequency of appendectomy for nonperforated appendicitis began to rise. What is one potential explanation for this observation?

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A. Increased use of diagnostic imaging and detection of appendicitis that otherwise would have resolved.

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B. Increased incidence of obesity and the impact of peri-appendicular fat on luminal obstruction.

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C. Increasing incidence of inflammatory bowel disease and the potential mitigation of ulcerative colitis symptoms seen with appendectomy.

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D. Reimbursement patterns have changed in the United States, favoring aggressive surgical decision making.

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Answer: A

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While the true reason is unknown, some have suggested that the quality and usage of diagnostic imaging in the past 20 to 30 years has resulted in the detection of acute appendicitis that would have otherwise spontaneously resolved. While appendectomy may mitigate the clinical symptoms of ulcerative colitis, this is likely not responsible for the broad reduction in observed appendectomy. Obesity is not known to impact appendicitis incidence. Reimbursement patterns should hopefully not impact surgical decision making so directly. (See Schwartz 10th ed., p. 1243.)

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What imaging finding would exclude appendicitis?

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A. A computed tomographic (CT) scan with a nonvisualized appendix.

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B. A barium enema where a short (2 cm) appendix was clearly identified.

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C. An ultrasound study with a compressible appendix that is <5 mm in diameter.

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D. A CT scan showing an edematous but retrocecal appendix.

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Answer: C

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Graded compression ultrasonography is inexpensive and rapid. The appendix is identified as a nonperistaltic, blind ending loop of bowel. The compressibility and anteroposterior dimensions are measured. Thickening of the wall as well as peri-appendiceal fluid with a noncompressible appendix are suggestive of appendicitis while an easily compressible, narrow appendix excludes the diagnosis. Failure to identify the appendix on imaging does not definitely rule out appendicitis. A fecalith in the mid appendix may allow proximal filling of the appendix with barium in the presence of appendicitis. Sonographic sensitivity for appendicitis is 55 to 96% while specificity is 85 to 98%. (See Schwartz 10th ed., p. 1245.)

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A 25-year-old man presents with migratory right lower quadrant (RLQ) pain, leukocytosis, and a CT scan consistent with acute, uncomplicated appendicitis. He is physiologically normal and it is 2 AM. You are planning an appendectomy, what difference might be expected in his outcome if his operation is delayed until the next morning?

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